Jockeying for position; the internal struggle in Congress will largely determine which health reform bill - and approach - comes out ahead - Cover Story

Business & Health, Jan, 1994 by Steven Findlay

Lawmakers are fond of repeating Otto Von Bismark's observation that there are two things you don't want to see being made: sausages and laws. If you have a queasy stomach at all, you may not want to watch the legislative process that is about to begin on health care reform. "It's not going to be a pretty sight," acknowledges Senate Majority Leader George Mitchell (D-Maine).

But it is going to be important. When the final town meetings and congressional hearings have been held, the decisions on the future of our health care system will get hammered out in subcommittee and committee rooms on Capitol Hill, mostly behind dosed doors.

The process itself which committees get jurisdiction over which part of what bill and what procedures will be followed in the debate--will have a major influence on the outcome. Indeed, the legislative bickering and posturing have already begun.

The Clinton health reform bill-- the Health Security Act--was formally introduced in Congress on Nov. 20, a month after it was unveiled. The White House politicked for weeks, but was only partially successful in picking up cosponsors. It ended up with 130--100 in the House and 30 in the Senate.

The major reason for the weak show of support was the five competing health reform bills that have been formally submitted to Congress. Two of the alternative bills effectively split the House into three coalitions the Clinton supporters (130); those backing the single-payer bill, the American Health Security Act, submitted by Rep. Jim McDermott D-Wash.), with 89 co-sponsors; and the major Republican offering in the House, the Affordable Health Care Now Act, submitted by Reps. Robert Michel (R-Ill.) and Newt Gingrich (R-Ga.), with 131 co-sponsors.

But the White House is most worried about a third bill, the Managed Competition Act of 1993, submitted by Rep. Jim Cooper (D-Tenn.). It stakes out the same centrist turf in the House that the administration has been claiming. And that bill could siphon off some Clinton bill supporters when the real political action starts.

Cooper's bill has 50 co-sponsors in the House, including 22 Republicans. He claims his is the only bipartisan bill. It is most noted for what it lacks: price controls and an employer mandate. Cooper calls his a "universal access" bill. The White House argues that the bill is inadequate because it will still leave millions of people uninsured, thus not achieving "universal coverage." Cooper, who plans to seek Al Gore's Senate seat in Tennessee next year, retorts that the nation can afford only to go to "second base" right now in reforming the system. "A new entitlement program is not the way to solve this problem," Cooper says. We'll attain universal coverage later when the savings from managed competition materialize, he adds. The Clintons' reply: Those savings won't materialize unless we cover everybody first and stop cost-shifting from the uninsured and uncompensated care.

Despite this fragmentation and the recent shift of focus to the Cooper approach, Clinton's bill is still strongly positioned. Several powerful House leaders are co-sponsors and are long-time advocates of sweeping health reform. They include Ways and Means Committee Chairman Dan Rostenkowski (D-Ill.), Energy and Commerce Committee Chairman John Dingell (D-Mich.), and Education and Labor Committee Chairman William Ford (D-Mich).

All three committees have significant jurisdiction over health reform, making it likely that the final version of a health reform bill in the House will retain major elements of the Clinton plan. But it doesn't mean these key lawmakers won't tussle over details with their committee members. Rostenkowski and Dingell , are single-payer sympathizers and will be pushing government controls. Joining them will be Pete Stark (D-Calif.), chairman of the Ways and Means Subcommittee on Health. Stark has been highly critical of the president's approach and has little faith that managed competition will control health care costs.

Positioning themselves against these Democrats are a group of Republicans girding for a major fight on the key health reform issues. In a landmark speech last month, Minority Whip Gingrich drew a hard line against Republican compromise with the Clinton plan. "At its core, this is a debate about who's going to control the health care system: government or the private sector. What the White House has put forward is a government-controlled system. We will oppose that vigorously," Gingrich says.

In the Senate, meanwhile, a dispute among Democrats over jurisdiction of health reform legislation broke out even before the president's bill was introduced. In the Senate, bills are usually referred to only one committee, the one with the "preponderance of jurisdictional claim." Sen. Edward M. Kennedy (D-Mass.), chairman of the Labor and Human Resources Committee, claimed this turf for his committee. Daniel Patrick Moynihan (D-N.Y.), chairman of the Senate Finance Committee, made the same claim for his committee. And Kennedy's committee went so far as to alter the bill in ways that would support its claim.